Etiology – Urease-producing bacteria, including Ureaplasma urealyticum and Proteus

species (most common), Klebsiella species, Pseudomonas species.

PREDISPOSING FACTORS RATIONALE

1. Sex (Female) A woman has a shorter urethra than a
man does, which shortens the distance
that bacteria must travel to reach the
bladder.
2. Neurogenic bladder Lacking bladder control due to a brain,
spinal cord or nerve problem can cause
urine leakage, urine retention and infection
to the bladder, ureter and urethra, this
makes the system vulnerable to bacterial
invasion.
3. Preexisting bacteria urease-producing bacteria (e.g. Proteus,
Klebsiella, Pseudomonas and Enterobacter)
are bacteria that influence the formation of
struvite stones that can lead to staghorn
calculi
4. Horshoe kidneys It is a disease where kidneys are fused
anomaly and could further lead to
complications such as renal stones,
infection and urinary problems which are
contributing factors for the development of
Staghorn calculi
5. Polycystic kidney disease It is a type of inherited disorder in which
clustered of cysts develop in the kidney
primarily leading to kidney damage
becoming vulnerable to infection.
6. Diabetes High glucose concentration in urine can be
a source of nutrients for bacteria, therefore
it can multiply and leads an infection.
Also High level of glucose in the blood can
cause nerve damage, affecting the
bladder’s ability to sense the presence of
urine, causing retention of urine increasing
the probability of infection.
 PRECIPITATING FACTORS
1. Poor hygiene
2. Client with urinary catheters
3. Dehydration
4. Low activity: Immobile
RATIONALE
Acquiring bacterial infections from the
lower GI tract ca be due to poor hygiene
such as wiping back to front after using the
toile or using contaminated water for
washing.
Having a catheter connected to the urethra
can be a pathway for bacteria and bacteria
can enter the urinary tract through the
catheter and causing an infection.
Lacking of water in the body can result to
high concentration of substance in the
urine. Not having enough liquid to dilute
these substance can influence stone
formation
When urine stays stagnant in the kidney, it
could cause the substance to combine and
forms a kidney stone
Symptomatology
Symptoms
1. Pain in your side and back
2. Fever
3. Frequent urination
4. Pain during micturition
5. Hematuria
6. Nausea and Vomiting
Rationale
Large stones can become lodged in the
ureter, blocking the flow of urine and
causing sharp pain in your back, side,
lower abdomen
Due to an occurrence of an infection,
there will be an immune response causing
the body temperature to increase to fight
off the infection.
As stones moves down to the bladder, a
client may feel an urgency to urinate.
Because of the preexisting infection,
inflammation in the urinary tract may
develop and causes pain during urination.
Also when large calculi that clogged in the
tract are push down it causes irritation
and intense pain.
Due to an irritation and abrasion of the
urinary tract cause by the kidney stones
presence of blood may occur.
Also it could be a sign that there is a
bacterial infection in the kidney
This happens due to the shared nerve
connections between kidneys and GI
tract, stones in the kidney may trigger the
nerves in GI tract, causing an upset
stomach.
Also may be due to an intense pain the
body releases adrenaline to escape the
threat felt by the body and this hormone
activates the alpha-adrenergic receptors
which responsible for pain-induced
vomiting
 Etiology: Urease-producing bacteria,
including Ureaplasma urealyticum and
Proteus species (most common),
Klebsiella species, Pseudomonas species

Predisposing Factors: Precipitating Factors:

1. Sex (Female) 1. Poor hygiene
2. Neurogenic Bladder 2. Client w/ urinary
3. Preexisting Bacteria catheter
4. Horshoe kidneys 3. Dehydration
5. Polycystic kidney 4. Low activity:
disease immobile
6. Diabetes

Proteus bacteria from the lower GI

tract colonize into the vagina

Proteus bacteria migrates to urinary

tract via urethral opening

Presence of Proteus bacteria in

Urinary system

Proteus bacteria releases urease

enzyme

Urease breaks down urea into

ammonia

A Ammonia B
 A B

Damages the glycosaminoglycan layer

that covers urothelial cells

Alkalizing the urine

Proteus bacteria will then attached
and colonize the surface of urothelium

Increase pH in Promotes crystallization of

biofilm magnesium ammonium
Proteus bacteria will then form a phosphate
biofilm

Proteus bacteria will then excrete

exopolysaccharide as part of biofilm
formation
 S/S: fever Increases pH level
Mgt. TSB

Results in to the precipitation of

struvite and apatite crystals within the
growing biofilm

S/S: Nausea and Vomiting

Mgt: Advice client to sit up or Crystallization continues to grow so as
lay down at his/her left side, the excretion of exopolysaccharide
eat small frequent meals,
advice to drink plenty of water
if not contraindicated.

S/S: Pain in the side or Mature struvite

back or during urination
Mgt: Encourage Deep stones
breathing exercise,
Analgesic
administration

Small Struvite Large Struvite

S/S: Hematuria stones flows down stones blocks the
Mgt: Collaborate w/ passage
to ureter
physician.

S/S: Urge to urinate

Mgt: Encourage fluid
intake if not Struvite stones continues
contraindicated to grow involving the renal STAGHORN
pelvis and calyces CALCULI
STAGHORN
CALCULI
 IF TREATED: IF NOT TREATED

Dx.

- CBC
Pyelonephritis
- Urinalysis
- 24-hr urine culture
- X-ray
- CT scan
- MRI scan Chronic irritation Sepsis Infection,
- Intravenous urography Inflammation

Medical Mgt.
- Acetohydroxamic acid Squamous
- Urease Inhibitors RENAL FAILURE metaplasia
- Genitourinary Irrigants
- NSAIDS

Surgical Mgt.
DEATH Squamous cell
- Extracorporeal shockwave lithotripsy carcinoma
- Percutaneous Nephrostomy
- Percutaneous Nephrolithotomy
- Laser and electroscopic lithotripsy

Nursing Mgt. POOR

PROGNOSIS
- Control pain
- Monitor UTI
- Strain the urine
- Maintain fluids 3 – 4L per day
- Strictly monitor I&O
- Encourage mobility
- Turn patient from time to time if immobile
- Patient education (Stones can reoccur)

PROGNOSIS:
GOOD
NARRATIVE:

Staghorn calculi is an upper urinary tract stone that involves the renal pelvis and
calyces. Staghorn calculi are commonly caused by the formation of large struvite stones
in the renal pelvis. However, there are rare cases where uric acid stones and calcium
oxalates develop into staghorn. A staghorn calculi that forms from a struvite stone is
composed of magnesium ammonium phosphate and urease-producing bacteria.
Risk factors that influence the development of the staghorn calculi are female sex,
neurogenic bladder, preexisting bacteria, horseshoe kidneys, polycystic kidney disease,
diabetes, poor hygiene, a client with urinary catheter, dehydration, and low activity or
immobile. Aside from these contributing factors, the most common causative agent of
the development of staghorn calculi from a struvite stone is urease-producing bacteria
like Proteus bacteria. Typical problems that arise from these bacteria are UTIs, and it’s
common in women due to reproductive anatomy. The process begins when Proteus
bacteria colonize in the reproductive system and migrates into the urinary system. In the
urinary system, Proteus bacteria releases an enzyme called urease enzyme. This
enzyme is responsible for breaking down the urea into ammonia and carbon dioxide.
The ammonia will then damage the glycosaminoglycan layer that covers urothelial cells.
The Proteus bacteria will then attach and colonize the surface of the urothelium, forming
a biofilm and excreting exopolysaccharide as part of biofilm formation. The release of
ammonia causes the pH in urine to elevate, making it alkaline that promotes
crystallization of magnesium ammonium phosphate, this could lead to the precipitation
of struvite and apatite crystals within the growing biofilm. As the biofilm grows, bacteria
will continue to excrete exopolysaccharide and develops into mature struvite stone that
is held by bacterial biofilm. It could be a small or large struvite stone, small ones can
pass through the ureter, but large ones may clog the flow obstructing the renal pelvis
where struvite stone could pile up and grow, covering the entire renal pelvis and calyces
forming Staghorn calculus.
Staghorn calculi can be diagnosed with CBC, urinalysis, 24-hr urine culture, x-ray, CT
scan, MRI scan, and intravenous urography. The condition can be managed medically
with urease inhibitor, genitourinary irrigants, NSAIDs, and surgically managed with
extracorporeal shockwave lithotripsy, percutaneous nephrostomy, percutaneous
nephrolithotomy, Laser and electroscopic lithotripsy. With the implementation of nursing
management such as controlling the pain, monitoring UTI, straining the urine for lab
purposes, maintaining fluid of client to 3 – 4L per day if not contraindicated, strictly
observe the intake and output, encourage mobility and turning the patient from time to
time if immobile, the good prognosis can be achieved. However, if the client is left
untreated, the condition may develop into pyelonephritis, sepsis, renal failure,
squamous cell carcinoma, and even death.